Key findings

Alcohol misusing elder abuse victims tended to be male, slightly younger than other victims, and abused by someone outside the family system. Their vulnerability for abuse seemed to be exacerbated by issues such as declining health, social isolation and possibly longstanding problems with alcohol.

Physical abuse was more commonly identified by practitioners in cases with alcohol misusing perpetrators.

Specialty alcohol practitioners described their role as minimising the vulnerability to misuse alcohol and thereby reducing the risks for abuse. Safeguarding practitioners reported their role as a regulated one and their priority was to respond to referrals of older alcohol misusing victims who lacked mental capacity.

Practitioners were most challenged by cases where alcohol misuse had led to self-neglect or where the perpetrator was an alcohol misusing family member.

Background

In 2000, the Department of Health’s No Secrets outlined a national framework for the development of local multi-agency codes of practice for the protection of vulnerable adults, representing one of the first policies that formalised the link between vulnerability, at any age, and abuse. As such, local council social services departments were required to act as lead agencies in developing strategic partnerships to implement the guidance on adult safeguarding.

Elder abuse falls within this guidance, and in 2012-13, 61% of all referrals to safeguarding in England were for people aged 65 years and older (Health and Social Care Information Centre (HSCIC), 2013). Alcohol misuse as a risk factor for abuse in older age is consistently identified in the literature, and yet little is understood about the nature of this relationship, its impact on older people and families, and what interventions are most effective. Its relevance to older people and abuse is significant in light of some of the adult drinking patterns in England. This study represents a first of its kind in England to begin to expand the elder abuse lens and focus attention alcohol misuse as a risk factor.

The purpose of this feasibility study was to collect substantive pilot data to scope the extent of alcohol-related elder abuse and neglect, and evaluate data sources and research methods to consider the development of a larger study on the role of alcohol misuse in cases of elder abuse and neglect. The research questions were as follows:

What is the relationship between alcohol misuse and elder abuse and neglect?

To what extent does alcohol misuse feature in elder abuse and neglect cases referred to local authority Safeguarding Adults Teams, and what are the key characteristics of such cases?

How do local authority Safeguarding Adults Teams and specialised alcohol treatment programmes perceive the role of alcohol misuse in relation to the problem of elder abuse and how are they responding to the problem?

What other professionals are mobilised by Safeguarding Adults Teams and specialised alcohol treatment programmes when there is alcohol-related elder abuse and neglect, and how do they work together to address the issue (s)?

In addition to conducting a review of the literature, including existing secondary data, new data was obtained from the following methods:

Using data from the case reporting requirements from one local authority Adult Safeguarding Team (2010/11 & 2011/12), descriptive detailed analysis was undertaken to identify the occurrence of alcohol-related elder abuse and neglect and case characteristics (N = 1,197).

A purposive sample of practitioners was recruited from a safeguarding team and specialty alcohol programmes for older people for in-depth interviews using the critical incident technique (N = 12).

Ethics approval was obtained from the School of Health Sciences and Social Care Research Ethics Committee, Brunel University.

Findings

Characteristics of alcohol-related elder abuse

The findings from this study provide further support for a relationship between alcohol misuse and elder abuse. The complex associations remain only partially understood, however, and further investigation warranted. Cases of elder abuse with alcohol involvement were identified when the victim was misusing alcohol, the alleged perpetrator and both victim and perpetrator. The nature of the abuse varied and different types of abuse were sometime co-present.

In cases where the victim was abusing alcohol, s/he was twice as likely to be financially abused as other victims. With supporting evidence from interviews with practitioners, it appeared that alcohol was a longstanding problem. The alcohol misuse appeared to contribute to increasing the person’s vulnerability for abuse from others, self-neglect or a complex combination of these. This vulnerability also seemed to be exacerbated by declining health or other psychosocial problems (e.g., loss, depression). The victim also tended to be male and slightly younger than other abused older people. The perpetrator, in these instances, was more likely to be from outside the family system.

In instances where only the perpetrator misused alcohol, s/he was more likely to be a family member. Physical abuse was also noted here. These cases were also complex ones given situation was likely to be compounded by difficult family dynamics. Unfortunately, less is known about perpetrators who misuse alcohol due to the nature of recording in case files and the absence of interventions with perpetrators. Understandings within the domestic violence literature were helpful here, but limited given its lack of attention of older victims.

Self-neglect and overlapping forms of abuse appeared most relevant in instances where both the victim and perpetrator(s) were misusing alcohol. The perpetrator was a friend or neighbour, the victim had a longstanding alcohol problem and had become socially distant from family. The older person seemed to have become vulnerable to other misusers over time – victims being reliant on the perpetrators to purchase alcohol, their home being used a drinking refuge and “people hanging around”, or perpetrators taking money and other personal items from the older person. Self-neglect, not typically within the mandate of safeguarding in England, was more typically managed by others and seemed to require longer term intervention to manage multiple vulnerabilities and/or risks.

Community-based interventions

The findings support the need for continued training in both abuse and misuse. Safeguarding practitioners did not appear to recognise alcohol misuse as a risk factor for elder abuse. Without exception they stated they were not trained to be aware or sensitive to this factor when conducting an investigation of alleged abuse. Where identified, their role was limited due to statutory regulation. They clearly stated their role was to ‘investigate’ alleged abuse and intervene, where necessary, to lessen further risk. Their role was to protect those older people who lacked mental capacity.Specialty alcohol practitioners, not available in many parts of the country, recognised alcohol misuse as increasing the older person’s vulnerability to a host of areas including elder abuse. Understanding that safeguarding services were not available to people with capacity, these practitioners typically had longer-term engagement with older people to first lessen vulnerability to drink and then to address other forms of vulnerability. They collaborated with safeguarding practitioners less frequently than expected.

Collaborative working in the instance of alcohol-related elder abuse was not viewed positively. Safeguarding practitioners were limited by their regulated role and tended to close cases promptly, thereby limiting longer-term engagement and mobilising community intervention. Specialty alcohol practitioners expressed frustration that the majority of professionals had negative views or misunderstood older people with alcohol-related problems.

Implications

A more comprehensive approach to vulnerable older people is required to more effectively address alcohol-related elder abuse. This includes, but not necessarily limited to:

The development of community-wide preventative strategies addressing both misuse and abuse in the older population.

The development of evidence-informed intervention strategies for alcohol-related elder abuse, including longer term professional engagement where necessary to provide ongoing support, advice and monitoring recognising that older people’s circumstances change over time. These strategies would reinforce that elder abuse is a responsibility for all services and the need to target resources for the provision of specialised alcohol programmes for older drinkers.

The development of person-centered interventions that are tailored to the nature of the abuse, associated risk factors and the older person’s circumstances. This involves the recognition that older people with capacity sometimes lack the ability to make decisions in absence of sustained support.

The provision of education and training for a wide range of health and social care practitioners to identify and intervene in cases of misuse and abuse.

Conclusion

This was a feasibility study exploring alcohol-related elder abuse with the view the findings would inform further investigation. Our findings continue to support alcohol misuse, whether victim or perpetrator, as a risk factor for abuse. Specific characteristics of alcohol-misusing victims and alcohol-misusing perpetrators identified in this study add to a growing body of literature on elder abuse and older drinkers, and enhance our understanding of the complexities of community-based care for an ageing population. We conclude that this study offers an opportunity to expand our empirical understandings of alcohol-related elder abuse through further mixed methods exploration in some of the following areas:

Further definition and characterisation of alcohol misuse as a risk factor for elder abuse (e.g., constructing explanations for who is misusing, nature of the misuse and abuse, relevance in family care system, self-neglect, relationship with other risk factors);

Exploration of practitioner assessment tools in relation to alcohol misuse and elder abuse; and

Developing and testing interdisciplinary social interventions, including education and training for practitioners and older people.